A nurse asks a client the current level of pain using a scale of 0 to 10 after administering pain medications 30 minutes ago. Which of the following steps of the nursing process is the nurse performing?

Analysis.

Implementation.

Planning.

Evaluation.

Answer and Explanation

The Correct Answer is D

The correct answer is choice D, Evaluation.

Evaluation is the step of the nursing process where the nurse assesses the client's response to interventions that were implemented during the implementation step. In this scenario, the nurse administered pain medication and is now evaluating its effectiveness by asking the client to rate their current level of pain on a scale of 0 to 10. Based on the client's response, the nurse can determine whether the intervention was successful or whether adjustments to the plan of care are necessary.

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Correct Answer is ["C","E"]

Explanation

The nursing actions that best represent the step of performing interventions in the nursing process are:

C. The nurse ambulates a post-operative patient in the hall during their shift.

E. The nurse turns a patient every 2 hours to prevent pressure injuries.

Explanation: In the step of performing interventions, the nurse takes action to implement the nursing care plan and achieve the identified goals. The interventions should be specific, measurable, and realistic to address the patient's needs. Ambulating a post-operative patient in the hall during their shift and turning a patient every 2 hours to prevent pressure injuries are both specific interventions that address patient needs and promote positive health outcomes. Removing bandages from a burn victim's arm and performing sterile dressing change once a shift is more related to the step of assessment or implementation, while identifying a patient's priority health problem or assessing a patient's nutritional status are more related to the step of analysis and diagnosis in the nursing process.

A. Turn client to the right. B. Clients with hip fractures cannot be turned. C. Keep client supine. D. Reposition client to the left.

Correct Answer is A

Explanation

The correct answer is choice A. When assisting a client with a fractured hip to turn in bed, the nurse should plan to turn the client to the unaffected side, which is the right side. This helps to reduce pressure on the affected hip, minimize discomfort, and prevent further injury. Clients with hip fractures (choice B) can and should be turned with proper positioning and assistance. Keeping the client supine (choice C) for extended periods can lead to pressure ulcers, discomfort, and other complications. Repositioning the client to the left side (choice D) can cause additional pressure and discomfort on the affected hip. Therefore, turning the client to the right is the best option for repositioning a client with a fractured left hip who has been lying in the supine position for an extended period.

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A nurse asks a client the current level of pain using a scale of 0 to 10 after administering pain medications 30 minutes ago. Which of the following steps of the nursing process is the nurse performing?

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Naxlex Comprehensive Predictor Exams

A nurse is taking action and performing interventions in the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step in the nursing process? Select all that apply.

Correct Answer is ["C","E"]

Explanation

The nurse is assisting a client who has a fractured left hip to turn in bed. The client has been laying in the supine position for 2 hours. How should the nurse reposition the client?

Correct Answer is A

Explanation

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